QUARTER THREE 2019 / VOLUME 28 / NUMBER 03 Medical MARIJUANA’S Effect on

WHAT’S INSIDE ADHD and Delayed Sleep Phase Syndrome May Be Linked Circadian Rhythm Sleep Disorders: An Overview and Sleep The Pros and Cons of Group Setups Alice 6 PSG systems

FULL PAGE AD Table of Contents QUARTER THREE 2019 VOLUME 28 / NUMBER 03

Medical Marijuana’s Effect on Sleep By Joseph Anderson, RPSGT, CCSH, RST, RPFT, CRT-NPS

Many states are adopting the use of marijuana for medical purposes even though federal law does not yet support marijuana to be used in this context. This article discusses its medical use, as well as its use in society historically and today. 10

Attention Deficit Hyperactivity Disorder and Delayed Sleep Phase Syndrome May Be Linked 15 By Regina Patrick, RPSGT, RST Circadian Rhythm Sleep Disorders: An Overview 18 By Peter Mansbach, Ph.D. Caffeine and Sleep 21 By Brendan Duffy, RPSGT, RST, CCSH The Pros and Cons of Group Setups 24 By Sarah Brennecka

DEPARTMENTS

President & Editor’s Message – 07

Trends – 25

In the Moonlight – 29

Compliance Corner – 30 FULL PAGE AD QUARTER THREE 2019 VOLUME 28 / NUMBER 03

THE OFFICIAL PUBLICATION OF AAST

ABOUT A2Zzz CONTRIBUTORS

A2Zzz is published quarterly by AAST. DISCLAIMER EDITOR The statements and opinions contained SUBMISSIONS Rita Brooks. MEd, RPSGT, REEG/ in articles and editorials in this magazine EPT, FAAST Original articles submitted by AAST are solely those of the authors thereof members and by invited authors will be and not of AAST. The appearance of MANAGING EDITOR considered for publication. Published products and services, and statements Alexa Schlosser articles become the permanent property contained in advertisements, are the sole of AAST. responsibility of the advertisers, including SENIOR WRITER Regina Patrick, RPSGT, RST PERMISSION TO USE AND REPRODUCE any descriptions of effectiveness, quality or safety. The editor, managing editor, AAST, A Zzz is published quarterly by AAST, CONTRIBUTING WRITERS 2 and the organization’s officers, regents, all rights reserved. Permission to copy members and employees disclaim all Joseph Anderson, RPSGT, CCSH, RST, or republish. A Zzz material is limited 2 responsibility for any injury to persons or RPFT, CRT-NPS by restrictions. property resulting from any ideas, products Peter Mansbach, Ph.D. Brendan Duffy, RPSGT, RST, CCSH ADVERTISING or services referred to in articles or Sarah Brennecka Advertising is available in A Zzz. Please advertisements in this magazine. 2 Matthew Anastasi, BS, RST, RPSGT contact the AAST national office for SUBMIT AN ARTICLE TO A ZZZ information concerning A Zzz rates and 2 ART DIRECTOR 2 Share your expertise with colleagues in policies, or find more details online at Bill Wargo the profession of sleep technology by www.aastweb.org. submitting an original article to A2Zzz. GRAPHIC DESIGNER

Read the A2Zzz Writer’s Guidelines at Alaina Kornfeld www.aastweb.org/publication-info. To propose an article topic or to get more information, send an email to [email protected].

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Quarter Three 2019 A2Zzz 5 SEPTEMBER 6-8, 2019 ST. LOUIS, MO

AAST 2019

ANNUAL MEETING

The AAST 2019 Annual Meeting is almost here! Secure your spot to join us in September and take your skills, knowledge and expertise to the next level, gaining insights into the evolving field of sleep. This year’s meeting features a variety of educational sessions, innovative industry keynotes, more dedicated time with exhibitors and the chance to connect with more than 300 fellow sleep professionals. LEADING EDUCATION

Maximum Pre-Meeting 21.5 CECs 2 Sessions

Education Keynote 18 Sessions 6 Presentations

Panel Exhibitors and 5 Presentations 30+ Sponsors

Sleep Professionals Dedicated 300+ and Subject 5.5 Exhibit Matter Experts Hall Hours

Learn more and register at www.aastweb.org/2019annualmeeting. President & Editor’s Message Professional Interests By Rita Brooks, MEd, RPSGT, REEG/EPT, FAAST

As we continue to expand our horizons As A2Zzz editor, I have the pleasure of and define who we are and our roles as seeing these new offerings before they are sleep professionals, continued learning disseminated, and I am always surprised is essential. As predicted way back in at the diversity of the new information 2013 at the AAST Summit, we are now becoming available that is useful for our commonly seeing more complicated members and readers. A2Zzz strives to patients in our sleep centers for testing include information that is applicable and more complicated treatments, both of to the night technologist facing more which require more knowledge and skill. complicated patients in the sleep center

I believe our roles will only continue to expand, and that as new knowledge becomes available, we will be able to leverage it to assist our patients.

In addition, more and more we are moving as well as the sleep educator and those in into clinical education roles and specialty other new and exciting roles. vendors are supporting this year’s roles in physician practices and hospital- This issue of A2Zzz offers a variety of meeting, including our faithful prestige based inpatient programs. information on new findings, including a partners and several new vendors with This wide range of new horizons has led possible connection between ADHD and interesting offerings. to a recent update of our Sleep Educator delayed sleep phase syndrome (DSPS) and The program includes cutting-edge job description to encompass some the possible benefits of medical marijuana topics that are sure to interest attendees, additional areas of expertise. I believe for sleep disorders. The Trends article in including a pre-conference session, our roles will only continue to expand, this issue explores the transition we are CCSH Workshop: AAST CCSH Designated and that as new knowledge becomes seeing from a “trade” to a “profession” and Education Program. Upon completion available, we will be able to leverage it to the education needs to get us there, and of this full-day workshop and receiving assist our patients. As professionals, we explores some of the new competencies a passing score on the online post-test, must remain current in our knowledge required in the sleep center. These RPSGT credential holders who have and provide education to our patients topics and more provide opportunity for recertified at least once will be eligible that is up to date and applicable. AAST continued learning that assists us to grow for the CCSH credential under a newly is working hard to keep up with all of the and to keep up with the latest information created BRPT pathway. new pertinent information that is coming in our field. I look forward to seeing you at the meeting out daily and provide excellence in The AAST Program Committee has in St. Louis. education for our members. prepared an excellent lineup for our AAST AAST’s foundation is education; our 2019 Annual Meeting. This year’s meeting Wishing you all a happy healthy summer. focus is on providing high-quality current in St. Louis is scheduled for Sept. 6-8 and Sleep well! educational offerings on an ongoing basis. there is still time to register. Numerous Rita

Quarter Three 2019 A2Zzz 7 Instructions for Earning Credit

AAST members who read A2Zzz and claim their credits online by STATEMENT OF EDUCATIONAL PURPOSE & OVERALL the deadline can earn 2.00 AAST Continu­ing Education Credits EDUCATIONAL OBJECTIVES (CECs) per issue, for up to 8.00 AAST CECs per year. AAST CECs A2Zzz provides current sleep-related information that is relevant are accepted by the Board of Registered Polysomnographic to sleep technologists. The magazine also informs readers about Technologists (BRPT) and the American Board of Sleep recent and upcoming activities of the AAST. CEC articles should Medicine (ABSM). benefit readers in their practice of sleep technology or in their To earn AAST CECs, carefully read the four designated CEC management and administration of a sleep disorders center. articles listed below and claim your credits online. You must go READERS OF A2ZZZ SHOULD BE ABLE TO DO online to claim your credits by the deadline of Nov. 14, 2019. THE FOLLOWING: After the successful completion of this educational activity, your • Analyze articles for information that improves their certificates will be available in the My CEC Portal acknowledging understanding of sleep, sleep disorders, sleep studies and the credits earned. treatment options COST • Interpret this information to determine how it relates to the

The A2Zzz continuing education credit offering is an exclusive practice of sleep technology learning opportunity for AAST members only and is a free benefit • Decide how this information can improve the techniques and of membership. procedures that are used to evaluate sleep disorders patients STATEMENT OF APPROVAL and treatments This activity has been planned and implemented by the AAST • Apply this knowledge in the practice of sleep technology Board of Directors to meet the educational needs of sleep You must go online to claim your CECs by the deadline of technologists. AAST CECs are accepted by the Board of Nov. 14, 2019. Registered Polysomnographic Technologists (BRPT) and the American Board of (ABSM). Individuals should only claim credit for the articles that they actually read and evaluate for this educational activity.

READ AND EVALUATE THE FOUR FOLLOWING ARTICLES TO EARN 2.0 AAST CECS:

Medical Marijuana’s Deficit Circadian Rhythm Sleep Caffeine and Sleep Effect on Sleep Hyperactivity Disorder Disorders: An Overview Objective: Readers should Objective: Readers should and Delayed Sleep Objective: Readers should understand that there are understand the history of Phase Syndrome May understand how the primary various opinions about how the medical use of cannabis Be Linked circadian rhythm sleep caffeine affects sleep. and the varying outcomes it Objective: Readers disorders disrupt people’s can have on individuals. should understand how lives and how the diagnosis ADHD and delayed sleep and treatment of these phase syndrome may disorders should focus on be linked, and how this personal fit. association could impact ADHD treatment.

Quarter Three 2019 A2Zzz 8 AAST Fundamentals TEXTBOOK

AAST has recently released the third edition of “Fundamentals of Sleep Technology.” This newly updated textbook provides comprehensive, up-to-date coverage of and other technologies in the evaluation and management of sleep disorders in adults and children.

Authored by Teofilo Lee-Chiong Jr., MD, Cynthia Mattice, MS, RPSGT, RST, and Rita Brooks, MEd, REEG/EPT, this edition has been extensively updated and expanded to reflect current practice, the latest technology, and the broader roles and responsibilities of the sleep technologist.

PURCHASE THE BOOK ON THE AAST WEBSITE

AAST members receive a 10% discount to purchase the book! Medical MARIJUANA’S EFFECT ON SLEEP

By Joseph Anderson, RPSGT, CCSH, RST, RPFT, CRT-NPS any states are on the intoxicating effects of bhang, a cannabis drink, to bridge heaven and earth. Some adopting the use researchers believe that kannabosm, a plant mentioned in the Old Testament as an of marijuana for ingredient in the sacred anointing oil, was an ancient name for cannabis. medical purposes even though federal Social Use law does not Though social use of marijuana has been occurring for centuries, it was during the 1960s Myet support marijuana to be used in this and 1970s when the social use of the plant experienced an explosion in modern culture context. Before we discuss its medical use, popularity. This popularity increase is partly attributed to music and social acceptance let’s discuss its use in society historically among the younger population of those decades. and today. Its use continued through the next several decades but seemed to slow in popularity when For centuries, the plant we commonly call employers began drug screening potential employees and with the increasing popularity of “marijuana” has been used for a variety other widely used substances such as cocaine. Cocaine’s water solubility made it less likely of reasons, including relaxation or fun, medical purposes, pain management, as a to remain in the human system and thereby harder to detect its casual use than marijuana. sleeping aid and social interactions. In the current decade, the use of marijuana has shown a dramatic increase. This might be Historical Use Ancient Hindus in India were against the use of alcohol but accepted social The effects of cannabis vary widely cannabis use. In ancient Rome, wealthy people finished banquets with a cannabis depending on the user, the strain, the seed dessert that was known for the “good feeling” it caused. At ancient Indian weddings, cannabis (bhang) was served dose and environmental factors. for good luck and as a sign of hospitality. Today, people often use cannabis for specific activities and occasions as well as contributed to more social acceptance, increased availability, decreased criminalization, perceived medical purposes. medical use and recreational use legalization in some states. Spiritual Use Medical Use Cannabis has a rich history of spiritual Cannabis has been used medically for thousands of years. In 2700 BCE, Shen Neng, use. It is listed as one of the five holy Chinese Emperor and father of Chinese medicine, used cannabis as a remedy for a variety plants in the “Atharvaveda,” a sacred Indian of ailments. The Ebers Papyrus, an ancient Egyptian medical text, also mentions cannabis. text from the second millennium BCE. It was written in 1500 BCE and is one of the oldest pharmaceutical works known. The Scythians, who lived in what is now Eastern Europe, used cannabis at funerals Over the past decade, research has focused more on the use of cannabis for medical to pay respect to departed leaders. purposes. Individuals with tend to use medical cannabis for sleep at a high rate. Ancient Chinese texts say Use for sleep is particularly common in individuals with PTSD and chronic pain. that cannabis can lighten When we ask what marijuana, or cannabis, does to our sleep, we are combining two a person’s body and vast unknowns: an insufficiently studied drug and a biological enigma. It is a universally allow them to acknowledged truth that marijuana can make you sleepy. Smokers everywhere have long communicate sought to learn exactly why. But this ignores a larger question; namely, how does it alter with spirits. sleep itself? They actually We know from studies on alcohol that falling asleep faster doesn’t necessarily correlate have been to better overall sleep. In fact, the opposite is true: Alcohol tends to disrupt our slumber, credited with as it can cause breathing problems or . So, before we can assume using “cannabis” marijuana is a way to get some shut-eye, let’s consider what it can do to your body and and would brain after it causes sleep. throw hemp seeds on The effects of cannabis vary widely depending on the user, the strain, the dose and hot rocks environmental factors. But the mechanism of its influence is always the same. Common inside enclosed research says marijuana influences the body’s endocannabinoid system, a complex tents and inhale network of receptors sensitive to chemical compounds found in the drug. the smoke. Researchers believe the endocannabinoid system plays a role in many of our daily biological The Persian prophet functions, from hormonal and immune function to the regulation of appetite and pain. It also Zoroaster (7 BCE) relied mitigates our stress and anxiety responses. You may have noticed that it’s hard to fall asleep

Quarter Three 2019 A2Zzz 11 if you’re not relaxed. New research suggests that cannabinoid signaling can directly promote sleep. All this gives scientists hope that we will eventually develop therapeutic drugs that rely on the endocannabinoid system to deliver their physiological benefits. For now, though, marijuana makes use of this fascinating part of our anatomy. And we are just beginning to understand the subtleties of how its cannabinoids can modify our nightly rest. The first thing to know about marijuana’s impact on sleep is that different cannabinoids have varying effects. The two main chemicals we are concerned with are THC, or tetrahydrocannabinol: the psychoactive ingredient that accounts for the marijuana ”high”; and CBD, or cannabidiol: a non-psychoactive substance increasingly valued for its therapeutic applications. THC reportedly promotes sleep by activating the endocannabinoid system’s CB1 receptors. It has also been widely properties,” as it increased awake activity during sleep and even counteracted the sedative reported that THC shortens the period of effects of THC. sleep latency and causes the users to sleep In a different experiment, rats that received doses of CBD took longer to fall asleep in the longer. Research also connects THC to an daytime but slept more overall and had a slight increase in slow-wave sleep — however, increase in slow-wave sleep, an essential not enough to be statistically significant. Since one consumes both these competing aspect of cerebral restoration and recovery. cannabinoids when marijuana is smoked, this could certainly account for mixed results in Other studies, meanwhile, show that CBD its confused reputation as a sleep aid. may keep us awake. One study found this Whether marijuana ruins your sleep is a subject of more dispute than whether it makes it cannabinoid to be “wake inducing.” Another easier to fall asleep on the couch. What’s less debatable is that both CBD and THC inhibit concluded that although THC appears to rapid-eye movement and the duration of REM sleep. Lack of REM sleep can lead to health be sedative, CBD appears to have “alerting conditions like migraines, and, as experts, we know REM sleep is crucial for proper rest. If you speak to someone who has suffered from insomnia at all as an adult, chances are good that person has either tried using marijuana for sleep or has thought about it. This is reflected in the many variations of cannabinoid or cannabis-based medicines available Research also to improve sleep such as Nabilone, Dronabinol and Marinol. Researchers seeking to learn how cannabis affects the sleeping brain have studied volunteers in the sleep laboratory connects THC and measured sleep stages and sleep continuity. It’s also a common reason for many cannabis users to seek medical marijuana cards. to an increase While there are still many questions to be answered, existing research suggests the effects of cannabis on sleep may depend on many factors, including individual differences, in slow-wave cannabis concentrations and frequency of use. Marijuana is the most common form of cannabis available in the United States and can vary widely in potency. sleep, an essential Some studies showed that users’ ability to fall and stay asleep improves with cannabis use. A small number of subjects also had a slight increase in slow-wave sleep. However, once nightly cannabis use stops, sleep clearly worsens across the withdrawal period. aspect of cerebral This research suggests that while motivation to use cannabis for sleep is high, and might initially be beneficial to sleep, these improvements might wane with chronic use over time. restoration Interestingly, when controlling for the presence of anxiety and depression, the differences disappeared. This suggests that cannabis’ effect on sleep may differ depending on and recovery. whether you have depression or anxiety. In other words, if you have depression, cannabis may help you sleep, but if you don’t, cannabis may hurt. One recent study showed

Quarter Three 2019 A2Zzz 12 the frequency of use seems to be an important factor as it relates to the effects on sleep. Thirty-nine percent of daily users complained of clinically significant insomnia. Meanwhile, only 10% of occasional users had insomnia complaints. Cannabis is still a Schedule I substance, meaning that the government does not consider cannabis to be medically therapeutic due to lack of research to support its benefits. This creates a barrier to research. Few universities in the country are permitted by the National Institute of Drug Abuse to grow marijuana for research. One university that is approved is the University of Mississippi. This is expected to change. New areas for exploration in the field of confidence in the state of the science or personal opinion. At this point, cannabis’ effect on cannabis research might examine how sleep seems highly variable, depending on the person, the timing of use, the cannabis type various cannabis subspecies influence and concentration, mode of ingestion and other factors. Perhaps the future will yield more sleep and how this may differ among fruitful discoveries. individuals. Research groups have been exploring cannabis types or cannabinoid concentrations that are preferable depending on one’s sleep disturbance. For example, one strain might relieve insomnia, While many people do swear by while another can affect . Other studies suggest that medical cannabis users with insomnia tend to prefer higher marijuana as a way to get a good concentrations of cannabidiol, a non- intoxicating ingredient in cannabis. night’s sleep, they may not be getting This raises an important question: Should the medical community communicate the kind of rest they need. these findings to patients with insomnia who inquire about medical cannabis? Some health professionals (and RTSleepWorld Vendor News on June 21, 2018, reported: “Melbourne, Australia-based some of you reading nasal respiratory company Rhinomed is pleased to advise investors that it has signed a this article) may not non-binding term sheet with Columbia Care LLC (“Columbia Care”) to license Rhinomed’s feel comfortable due nasal platform for the delivery of medical cannabis and cannabinoid compounds, analogs to the fluctuating and derivatives.” legal status, a lack of All of this is to say: While many people do swear by marijuana as a way to get a good night’s sleep, they may not be getting the kind of rest they need. As with every topic in marijuana science, the matter of its effect on sleep is still up for debate, thanks in part to federal prohibition.

JOSEPH ANDERSON, RPSGT, CCSH, RST, RPFT, CRT- NPS, is an EEG and sleep patient care coordinator at SOVAH Health in Martinsville, Virginia.

Quarter Three 2019 A2Zzz 13 AAST Learning Center Your One-Stop Shop for Online Education

The AAST Learning Center is accessible 24/7 and provides you with on-demand videos, advanced learning modules that you can start and stop on your schedule, conference recordings and more!

Discover relevant educational content by searching by content type or topic area and access the Case of the Month, Journal Club and CECs all through the AAST Learning Center. A2Zzz

Get started at www.aastweb.org by checking out the latest offerings, including the AAST 2018 Annual Meeting Recordings. Attention Deficit Hyperactivity Disorder and Delayed Sleep Phase Syndrome May Be Linked By Regina Patrick, RPSGT, RST

The prevalence of certain sleep disorders such as obstructive , insomnia Bright light therapy is the strategic use of and restless legs syndrome are increased among children and adults with attention strong-intensity light to shift a person’s deficit hyperactivity disorder (ADHD).1 In 1991, Dahl and colleagues2 reported a possible circadian phases earlier or later. The link between ADHD and a circadian disorder in their case report of a 10-year-old girl intensity of the light is stronger than that who had ADHD and delayed sleep phase insomnia. Chronotherapy with behavioral of natural light and can temporarily stop modification significantly improved her ADHD symptoms and increased her sleep time the production of . Exposure to by approximately 29%. In 2000, Gruber and colleagues3 more objectively corroborated a bright light soon after awakening advances possible link between ADHD and sleep-onset insomnia, based on actigraphy and sleep the sleep/wake phases, whereas exposure diary data. In 2005, Van der Heijden and colleagues4 suggested that sleep-onset insomnia to bright light soon before going to in children with ADHD was in actuality a symptom of delayed sleep phase syndrome delays the sleep/wake phases. People with (DSPS), based on the finding that the onset of dim light melatonin production was DSPS typically undergo morning bright delayed. Some scientists now believe that ADHD and DSPS are linked5 and believe that light therapy for several days to advance an estimated 73-78% of children and adults with ADHD also have DSPS.6 In recent years, their sleep/wake phases. Once the phases scientists have begun investigating whether treating DSPS in people with comorbid ADHD are shifted to a desired time, the person 7,8 and DSPS improves ADHD symptoms. then maintains bright light exposure at People with ADHD have difficulty focusing on tasks (i.e., inattention) and may act the same time daily to prevent the relapse impulsively. They may behaviorally be disorganized, restless and virtually always in motion of DSPS. (i.e., hyperactive). Symptoms of ADHD often begin in childhood and, in some people, The sleep-promoting hormone melatonin continue into adulthood. Hyperactivity tends to improve by the teen years, whereas is produced in the pineal gland, which problems with inattention, disorganization and poor impulse control often continue receives signals from the eyes about into adulthood. light intensity. During the night, melatonin Stimulant medications are the first line of treatment for people with ADHD. Stimulant normally rises to its highest level and, medications ironically reduce hyperactivity and impulsivity and improve a person’s ability during the daytime, it falls to its lowest to focus, work and learn. The reasons for this effect are unclear. A possible explanation level. To prevent sleep-onset insomnia, may be that stimulants increase brain levels of the neurotransmitter dopamine, which is a person with DSPS takes melatonin a involved in thinking and attention.9 few hours before to increase the Antidepressants such as tricyclic drugs (e.g., amitriptyline, desipramine) are sometimes melatonin level and aid used to treat adults with ADHD, although antidepressants are not approved for treating the onset of sleep at ADHD. Tricyclic drugs affect brain levels of norepinephrine and dopamine, which may a desired time. enhance a person’s ability to focus and reduce hyperactivity. In chronotherapy, Behavioral therapy and psychological counseling can be helpful for people with ADHD. the bedtime and Behavioral therapy can involve maintaining a routine schedule; organizing everyday items; awakening time and, for children, using homework and notebook organizers, and giving praise or rewards of a person with when rules are followed. A therapist can help adults with ADHD with organizing their life DSPS is set one with tools such as maintaining a routine and breaking large tasks into smaller tasks. to three hours later each day In people with DSPS, the sleep/wake phases occur later than normal. Thus, they naturally over several want to go to sleep in the early morning hours (e.g., one to three hours after midnight) and days until awaken late in the morning (e.g., 10-11 a.m.). the person’s When trying to follow the societally “normal” schedule, people with DSPS have difficulty sleep/wake initiating sleep at night (i.e., insomnia) and awakening in the morning. When not following phases occur a “normal” schedule, the person’s sleep duration and quality is normal, but the sleep and at a desired wake phases are delayed. The disorder typically manifests during the teen years. time. The The goal of DSPS treatment is to shift the sleep/wake phases to a more socially schedule is then “normal” time. This shift can be accomplished by bright light therapy, melatonin therapy strictly maintained and chronotherapy. at the desired hours

Quarter Three 2019 A2Zzz 15 to prevent a relapse of DSPS. In people with DSPS, the sleep/wake phases are already Scientists have yet to definitively naturally delayed. Therefore, further delaying the phases to a desired time may be more confirm that DSPS and ADHD are linked, efficacious than attempting to advance them in some people. although the possibility that DSPS How ADHD and DSPS are pathophysiologically linked is unclear. Alterations in brain is an aspect of ADHD appears to be regions involved in sleep, wakefulness, learning, cognition and motor activity could be a gaining acceptance, as expressed by possible link, as indicated in some recent research. researcher Sandra Kooij at the 30th European College of Neuropharmacology Cerebral blood flow and the activity of certain neural networks are altered in adults with Conference (Paris, France) in 2017: “It ADHD. Some of the same areas are also involved in wake and sleep. For example, Tan and looks more and more like ADHD and colleagues10 demonstrated that, compared to healthy controls, adults with ADHD have sleeplessness are two sides of the same reduced blood flow in the limbic network (which is involved in emotions and in certain physiological and mental coin … If the connection is confirmed, it raises the intriguing question: Does ADHD cause sleeplessness, or does sleeplessness Recent research indicates that the cause ADHD? If the latter, then we may be able to treat some ADHD by pineal gland volume is smaller in nonpharmacological methods, such as changing light or sleep patterns, and people with ADHD than in people prevent the negative impact of chronic sleep loss on health.”5 Kooij cautions that without ADHD. all ADHD symptoms cannot be attributed to an abnormal circadian rhythm but believes an abnormal circadian rhythm is an important element of ADHD. aspects of sleep) and in subcortical regions (e.g., the basal ganglia, a group of specialized Standard pharmacological treatments neurons at the base of the brain that are involved in a variety of functions such as sleep/ for ADHD often do not fully control wake cycles, the control of voluntary motor movements, procedural learning, habit ADHD symptoms. Residual symptoms in learning, eye movements, cognition and emotion). some people may result from underlying Imeraj and colleagues11 suggest that altered circadian rhythms in people with ADHD may untreated DSPS. In addition, the long- result from dysfunction of the locus coeruleus. The locus ceruleus is a blue-tinged area term use of drugs to treat ADHD can on the back of the brainstem near the cerebellum that is involved in the onset and offset have adverse effects such as addiction of and in other aspects of sleep and wake, and in circadian and cardiovascular problems (e.g., heart rhythmicity. It is also involved in movement. In people with ADHD, the arousal processes valve problems, hypertension, stroke, involving the locus ceruleus may be altered. arrhythmias and cardiomyopathy). The Alterations in the pineal gland may be involved in the coexistence of ADHD and DSPS. The finding that DSPS often coexists with pineal gland produces melatonin and is involved in circadian rhythms and in circadian ADHD may provide another treatment preference (i.e., whether a person is a “morning” person or an “evening” person). This gland approach for some people with ADHD. also has a role in movement. Recent research12 indicates that the pineal gland volume is Adding DSPS treatment (bright light smaller in people with ADHD than in people without ADHD, and that people with ADHD tend therapy, etc.) with the standard treatment to have an “evening” circadian preference, which may be related to the reduced volume. could potentially reduce a person’s need for stimulant medications and provide Such findings are interesting. However, more studies are needed to determine whether more effective relief from symptoms. ADHD and DSPS have a shared pathophysiology. It would seem that treating DSPS in people with ADHD would impact ADHD symptoms. References To test this possibility, Fargason and colleagues8 used bright light therapy to advance 1. Walters AS, Silvestri R, Zucconi M, et al. the circadian rhythms in people with coexisting ADHD and DSPS. The researchers also Review of the possible relationship and assessed whether bright light therapy could reduce ADHD symptoms. The study participants hypothetical links between attention deficit underwent two weeks of morning bright light therapy, after undergoing a one week baseline hyperactivity disorder (ADHD) and the assessment. All participants wore an actigraphy watch to monitor changes in nocturnal simple sleep related movement disorders, and diurnal activity levels. The baseline and post-treatment onset of dim light melatonin , , and circadian production times were compared. A questionnaire was used to measure ADHD symptoms. rhythm disorders. Journal of Clinical Sleep Fargason found that bright light therapy significantly advanced the onset of dim light Medicine. 2008;4:591-600. melatonin production. This phase advance was significantly correlated with a decrease 2. Dahl RE, Pelham WE, Wierson M. The role in ADHD symptoms and in hyperactivity-impulsivity. Based on these findings, Fargason of sleep disturbances in attention deficit suggests that bright light therapy could be a complementary treatment for adults with DSPS disorder symptoms: a case study. Journal of and ADHD symptoms. Pediatric Psychology. 1991;16:229-239.

Quarter Three 2019 A2Zzz 16 3. Gruber R, Sadeh A, Raviv A. Instability of sleep patterns in children with attention-deficit/ 11. Imeraj L, Sonuga-Barke E, Antrop, I, et al. hyperactivity disorder. Journal of the American Acadamy of Child and Adolescent Psychiatry. Altered circadian profiles in attention-deficit/ 2000;39:495-501. hyperactivity disorder: an integrative review 4. Van der Heijden KB, Smits MG, Van Someren EJ, et al. Idiopathic chronic insomnia and theoretical framework for future studies. in attention-deficit/hyperactivity disorder: a circadian rhythm . Chronobiology Neuroscience and Biobehavioral Reviews. International. 2005; 22:559-570. 2012;36:1897-1919. 5. Kooij S. Circadian rhythm and sleep in ADHD—cause or life style factor? 30th Annual ECNP 12. Bumb JM, Mier D, Noelte I, et al. Congress; held on September 2–5, 2017, 2017. Available at https://www.ecnp.eu/~/media/Files/ Associations of pineal volume, ecnp/About%20ECNP/Press/2017/Kooij%20pr%20FINAL_Sunday.pdf?la=en; Paris, France. and symptom severity in 6. Bijlenga D, Vollebregt MA, Kooij JJS, et al. The role of the circadian system in the etiology and adults with attention deficit hyperactivity pathophysiology of ADHD: time to redefine ADHD? ADHD Attention Deficit and Hyperactivity disorder and healthy controls. European Disorders. 2019;11:5-19. Neuropsychopharmacology. 2016;26: 1119-1126. 7. Gradisar M, Dohnt H, Gardner G, et al. A randomized controlled trial of cognitive-behavior therapy plus bright light therapy for adolescent delayed sleep phase disorder. Sleep. 2011;34(12):1671- 1680. REGINA 8. Fargason RE, Fobian AD, Hablitz LM, et al. Correcting delayed circadian phase with bright light PATRICK, therapy predicts improvement in ADHD symptoms: a pilot study. Journal of Psychiatry Research. 2017;91:105-110. RPSGT, RST, has been in the sleep 9. US Department of Health and Human Services, National Institutes of Health. Attention-deficit/ hyperactivity disorder (ADHD): the basics. In. Bethesda, MD: National Institute of Mental Health; field for more than 2019. Available at https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity- 20 years and works disorder-adhd-the-basics/index.shtml. as a sleep 10. Tan YW, Liu L, Wang YF, et al. Alterations of cerebral perfusion and functional brain connectivity in technologist at the medication-naive male adults with attention-deficit/hyperactivity disorder. CNS Neuroscience and Wolverine Sleep Disorders Center in Therapeutics. 2019. doi: 10.1111/cns.13185. Tecumseh, Michigan.

Quarter Three 2019 A2Zzz 17 Circadian Rhythm Sleep Disorders: An Overview By Peter Mansbach, Ph.D.

Takeaways asleep very early in the evening and waking up in the very early morning hours, unable to sleep further. • Not only is the internal clock shifted, but the patient is unable to shift it back. Non-24-hour sleep-wake disorder (non-24) (also called free running disorder) is a condition in which a person’s day length is significantly longer than 24 hours, so that sleep • These disorders disrupt people’s times get later each day, cycling around the clock in a matter of days or weeks. lives and may have other health consequences. Two Factors • Treatments are often ineffective. • When performing a , the time There are two factors to these disorders. One is that the body’s internal clock is shifted should be scheduled to conform to the with respect to the external day-night cycle. The other is that it is difficult or even 3 patient’s internal clock. impossible to shift back to a normal sleep schedule. That is the part that people who have not experienced these disorders find so difficult to understand. Introduction Even when physically tired or sleep deprived, these people often cannot make up for lost sleep outside of their hardwired sleep times. I have delayed sleep phase disorder (DSPD). That means I am unable to fall Most people can adjust their sleep times with sufficient discipline.e W cannot. asleep until very late at night and normally sleep very late in the morning. My sleep Prevalence doctor sent me to a sleep lab to get a A careful survey of 10,000 adults concluded that 0.17% had clinically diagnosable DSPD.4 polysomnogram. The lab techs insisted I That’s about one in 600, or half a million Americans. Three times as many as have try to sleep at midnight, and they woke me . Yet it often goes undiagnosed, in part because people, even doctors, are at 5 a.m. The sleep doctor then informed unaware of these disorders. me that my problem was I wasn’t getting It is well-known that circadian rhythms often shift later during adolescent years,5 so DSPD any deep sleep. No, not between midnight is much more prevalent among teens. and 5 a.m. — I could have told her that. The same survey4 didn’t find any cases of ASPD. Additionally, ASPD is less frequently Definitions1,2 diagnosed because it doesn’t cause patients to be late for work or school, so they are less likely to seek medical help. Circadian rhythms are physiological, and It is estimated that over half of all totally blind people have non-24. However, some behavioral changes in the body that occur sighted people also suffer from non-24. Sighted non-24 was thought to be extremely rare, on roughly a 24-hour cycle. Examples are but our own survey6 and discussions on social networks suggest it is more common than sleep, alertness, core body temperature, previously thought. appetite and many hormones. Circadian rhythm sleep disorders (CRSDs) Impact are neurological disorders in which the sleep-wake cycle is out of sync with the Damned if you do. day-night cycle. We focus on these three: Most people with these disorders try to live on a normal schedule. School or work delayed sleep phase disorder, advanced requirements enforce this. These people often get less than six hours of sleep a night6 and sleep phase disorder and non-24-hour become sleep deprived. Many report sleeping through loud alarm clocks. They are often late sleep-wake disorder. for work and often lose their jobs. Delayed sleep phase disorder (DSPD) is characterized by an inability to fall asleep until very late at night, with the resulting need to sleep late in the morning or into Most people can adjust their sleep times the afternoon. Advanced sleep phase disorder (ASPD) is with sufficient discipline. We cannot. the opposite. It is characterized by falling

Quarter Three 2019 A2Zzz 18 Personal Experiences Back when I was attending college, and later working a daytime job, I was always slightly depressed, and twice had major depressive episodes lasting many months, with suicidal feelings. After my DSPD was diagnosed and I started living on my body’s preferred schedule, the depression lifted. My mood is now quite normal, and I have a positive outlook. Once, when I had to get up very early for an important meeting, I drove to work, and in my sleepy fog, I drove onto a highway using the off ramp. If you’ve never faced a stream of automobiles coming at you at 60 miles an hour, I don’t recommend it. Fortunately, adrenaline kicked in, and I was able to get to the shoulder quickly. More generally, even getting up a few hours early leaves me somewhat dysfunctional for a day or two and not able to perform well in my work. I’ve learned to insist on afternoon appointments. One DSPD patient wrote me saying, “For decades, I worked day jobs after sleeping These folks drag themselves through 3:30-7:30 a.m., catching up on weekends … That worked while I was young and resilient. one day after another. The struggle with Next step was adding a long ‘’ from 5-10 p.m. Wreaks havoc with the social life, but , day in and day out, is wearing it kept me my job for years. If you can’t be normal, you’re not good enough. You learn to and can lead to depression. At best, these apologize, make excuses, tell lies. No one understands.” people are not able to function well. Like A non-24 patient wrote me saying, “I no longer live in a 24-hour day. I live in a 27-hour most sleep-deprived people, they are at day … I can’t predict how much forward I will move, and I can’t stop it. There isn’t a cure. greater risk of automobile accidents. There are treatments, but their success rate is low, and they have proven unsuccessful for In the long term, they are destroying their me … As you can imagine, not having a consistent schedule means that I cannot work a health. The constant normal job, or any job. No one wants to employ me in the United States. The ADA doesn’t can lead to cancer, diabetes, fibromyalgia, help me because they do not consider my disability to be worth accommodating.” depression and other illnesses.7, 8 Damned if you don’t. Diagnosis Some people have been happier and The first hurdle for people suffering from constant tiredness is to get their primary care healthier sleeping on their bodies’ preferred doctor to refer them to a sleep specialist. Too often the primary doctor treats the problem schedules. However, they have great as insomnia and prescribes sleeping pills or blames it on depression when the real difficulty finding regular work. Some culprit is the underlying circadian disorder. We know of too many people who went for manage by doing freelance work if they years being repeatedly misdiagnosed and often given medications with side effects for have marketable skills. But when living on conditions they didn’t have. their bodies’ preferred schedules, they also The sleep specialist often refers the patient to a sleep laboratory for an overnight sleep have difficulty scheduling appointments, study. This can diagnose or rule out other disorders such as sleep apnea or restless legs getting repairs on their homes or even being syndrome. Often a multiple sleep latency test (MSLT) is prescribed to check for narcolepsy. available to their children when needed. But there is a problem. Most sleep studies are conducted during normal sleep hours. This may In addition, they often lack support from not be valid for someone with a circadian rhythm sleep disorder, who sleeps on a different family, friends and the medical community, schedule. It is known, for example, that the MSLT can yield false positives for people working and are called lazy and undisciplined by the night shift.9 Surely the same applies to a DSPD patient working a 9-to-5 day shift. those who do not understand the severity Scheduling is particularly difficult for non-24 patients, because they often cannot predict of these disorders. Patients not only have to deal with their disorder, but they have where their schedule will be far enough in advance to schedule the study. to fight with the people who should be supporting them. Treatment It has been suggested — without Treatment attempts to shift the patient’s circadian rhythm to fit conventional job schedules. supporting data — that people with Three treatments are generally suggested: light therapy, light restriction and melatonin. All circadian rhythm sleep disorders who three may be used together. This assumes normal is already being followed. sleep on their bodies’ preferred schedule Light therapy involves exposure to bright light. For DSPD and non-24 patients, this would sleep well, wake up refreshed and feel be in the morning; for ASPD patients, it would be at night. alert during their awake time. Anecdotal Light restriction for DSPD and non-24 means limiting light exposure to only very dim light evidence and our own survey data6 contradict that. Many of us wake up in the evening. Light containing a lot of blue should particularly be avoided. groggy, struggle for hours to wake up fully Melatonin, prescribed as a chronobiotic to shift circadian rhythm, should be taken four and are still not at peak alertness. to eight hours before bedtime. The same dose of melatonin gives rise to widely varying

Quarter Three 2019 A2Zzz 19 serum levels,10 so it is recommended to It seems likely that different patients may have different underlying causes. DSPD, for start with a small dose, perhaps one- example, is a symptom, as fever is a symptom, but it may have different causes in quarter milligram, and titrate from there. different people. That would explain the low success rates of the various treatments, Too high a dose so long before bedtime which are not being tailored to the underlying cause. may make the patient sleepy. Melatonin has also been prescribed as a hypnotic to Conclusion help the patient fall asleep more quickly. Further research is sorely needed. The American Academy of Sleep Medicine (AASM), As a hypnotic, it is taken shortly before Sleep Research Society (SRS) and Society for Research on Biological Rhythms (SRBR) are bedtime, but that is less effective in drafting a white paper on needed research, and Circadian Sleep Disorders Network has shifting the circadian rhythm. submitted its priorities.16 For all three treatments, we suggest initially basing the timing on the patient’s current References circadian rhythm and gradually shifting the These are examples; many more supporting references are available: time earlier (for DSPD) or later (for ASPD) 1. Circadian Sleep Disorders Network: https://www.circadiansleepdisorders.org/. until reaching the desired sleep time. Trying 2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth to shift the rhythm all at once may result in Edition (DSM-5) (2013). the opposite effect from that desired — for 3. ICSD-R (International Classification of Sleep Disorders, Revised), American mAcademy of Sleep example, making DSPD sleep time still later Medicine, 2001, p.130. based on the phase response curves for light and melatonin.11, 12 4. Schrader H, Bovim G, and Sand T, The prevalence of delayed and advanced sleep phase syndromes (J Sleep Res. 1993 Mar;2(1):51-55). These treatments, alone or in combination, 5. Carskadon, MA, Sleep in Adolescents: The Perfect Storm (Pediatr Clin North Am. 2011 Jun; 58(3): help some people normalize their sleep and 637-647). circadian rhythm. For too many others, the 6. Circadian Sleep Disorders Network, Some Preliminary Survey Results, www. treatments are not effective.6, 13 Forcing the CircadianSleepDisorders.org/registry/survey_results_prelim2.php. Further results to be published. patient to sleep at specified times, when it results in extreme tiredness, continues the 7. Gale JE, Cox HI, Qian J, et al, Disruption of Circadian Rhythms Accelerates Development of deleterious effects of sleep deprivation on Diabetes through Pancreatic Beta-Cell Loss and Dysfunction, J Biol Rhythms 26, 5, 423-433. the patient’s long-term health. 8. Scheer FA, Hilton MF, Mantzoros CS, Shea SA, Adverse metabolic and cardiovascular consequences of circadian misalignment, Proc Natl Acad Sci U S A. 2009 Mar 17;106(11):4453-8. Questionable Treatments 9. Goldbart A, Peppard P, Finn L et al, Narcolepsy and predictors of positive MSLTs in the Wisconsin Sleep Cohort, Sleep. 2014 Jun 1;37(6):1043-51. Phase-delay chronotherapy for DSPD — delaying sleep time several hours later 10. Aldhous M, Franey C, Wright J, and Arendt J, Plasma concentrations of melatonin in man following oral absorption of different preparations (Br J Clin Pharmacol. 1985 Apr; 19(4): 517–521). each day until arriving at the desired schedule — should no longer be 11. St. Hilaire, MA, Gooley, JJ, Khalsa, SBS, et al, Human Phase Response Curve (PRC) to a 1-hour recommended. Effectiveness is short-term pulse of bright white light (J Physiol. 2012 Jul 1;590(Pt 13):3035-45). at best,6 and may lead to non-24, which is 12. Burgess HJ, Revell VL, Molina TA, Eastman CI, Human phase response curves to three days of far more difficult to live with.6, 14 daily melatonin: 0.5 mg versus 3.0 mg (J Clin Endocrinol Metab. 2010 Jul;95(7):3325-31). Sleeping pills may put patients to sleep, 13. Yamadera H, Takahashi K, Okawa M, A multicenter study of sleep-wake rhythm disorders: therapeutic effects of vitamin B12, bright light therapy, chronotherapy and hypnotics, (Psychiatry but they do not shift the circadian rhythm. Clin Neurosci. 1996 Aug;50(4):203-9). The sleep may not be restorative, and the other health issues arising from disordered 14. Oren DA and Wehr, TA, Hypernyctohemeral Syndrome after Chronotherapy for Delayed Sleep circadian rhythm are likely unresolved. Phase Syndrome (N Engl J Med 1992; 327:1762). 15. Sack, RL et al, Circadian Rhythm Sleep Disorders: Part II, Advanced Sleep Phase Disorder, Delayed Causes Sleep Phase Disorder, Free-Running Disorder, and Irregular Sleep-Wake Rhythm (Sleep. Nov 1, 2007; 30(11): 1484-1501, Section 12.1). Several possible underlying causes of 16. Circadian Sleep Disorders Network, Needed Research, https://www.circadiansleepdisorders.org/ circadian rhythm sleep disorders have docs/NeededResearch.php. been proposed, including a very long circadian rhythm (or short, for ASPD), lack of sensitivity to light, over-sensitivity PETER MANSBACH, PH.D., is founder and president of to light, deficiencies in the intrinsically Circadian Sleep Disorders Network, an independent nonprofit photosensitive retinal ganglion cells organization dedicated to improving the lives of people with (ipRGCs), lack of melatonin production, chronic circadian rhythm sleep disorders. long elimination time of melatonin, differences in timing of sleep relative to internal circadian rhythms, etc.15

Quarter Three 2019 A2Zzz 20 Caffeine and Sleep By Brendan Duffy, RPSGT, RST, CCSH

I recently spoke with several sleep experts about caffeine and sleep. These wonderful and takes up to eight hours or more to sleep professionals were very giving of their time and knowledge, and I thank them leave the body. So, we know when people immensely. It is because of their willingness to share their time, thoughts and friendship have caffeine when going to bed, that that I can share this information with you. actually delays sleep onset. We also see it Below is a summary of the questions I posed — and some of their responses. So, pour can cause disruptions in sleep after sleep yourself a “Double Ristretto Venti Half-Soy Nonfat Decaf Organic Chocolate Brownie onset, which means more awakenings Iced Vanilla Double-Shot Gingerbread Frappuccino Extra Hot with Foam Whipped Cream throughout the night. Upside Down Double Blended, One Sweet’N Low and One NutraSweet” — or perhaps just As for the second part of the question a refreshing glass of ice water — and enjoy this coffee break with sleep experts. about reaction time, this is interesting In what ways does caffeine affect sleep, and are there benefits because the data in athletes is a little to using caffeine as a way to increase alertness and/or bit contradictory in some ways; in some reaction time? studies, it does increase alertness and, in some, it does not. It depends how Dr. Jaques Reifman, Ph.D., senior research scientist, U.S. Army: you want to quantify alertness and/or https://www.sciencedaily.com/releases/2018/06/180604093116.htm reaction time. What is interesting is if we look at military studies where people are Caffeine binds to brain receptors ( receptors, which, when activated by taking caffeine after sleep deprivation to adenosine, promote sleepiness and suppress arousal). Hence, when caffeine, instead of negate the effects of sleep deprivation. In adenosine, binds to these receptors, it inhibits the slowdown of neural activity and reduces a military study where reaction time was your feeling of sleepiness. Therefore, caffeine acts as a stimulant to the central nervous system, promoting alertness and reducing reaction time. being tested, they found that reaction time improved but accuracy diminished. We Dr. Ian Dunican, Ph.D., MineEng, MBA, GCASSc, BA, sleep and have also seen with athletes as well that performance expert: excessive use of caffeine may increase Twitter: @sleep4perform alertness and reaction time, but it may lead to cramping. Although, again, the literature Caffeine affects sleep mainly by delaying sleep onset. As we know from the is divided, and there is no direct correlation pharmacokinetics, it takes an hour to peak, has anywhere from a four- to six-hour half-life, on that, but we have seen anecdotally in athletes that they do cramp within 60- 70 minutes after consuming excessive caffeine levels.

Dr. Marta Maczaj, AASM Board certified sleep physician; co-director, St. Charles Sleep Disorders Center, Port Jefferson: https://stcharleshospital.chsli.org/sleep- disorders-center Although a cup of coffee (or other caffeinated beverage) in the morning should not interfere with your ability to sleep at night, some individuals are sensitive to caffeine. Others may metabolize caffeine more slowly, and these individuals could have difficulty falling asleep due to the caffeine. Caffeine

Quarter Three 2019 A2Zzz 21 is found in many substances, not just coffee. It is present in black tea, green tea, soda, What would you like chocolate and energy drinks. people to know about Although it is usually OK to have a caffeinated drink up until noon, if you are having trouble caffeine metabolism? falling asleep or staying asleep, then you should consider either restricting or eliminating caffeine intake. Dr. Jacques Reifman: In our mathematical model, we account Dr. Daniel Erichsen, sleep physician: for the pharmacokinetics of caffeine (PK: https://www.youtube.com/channel/UC_tdQDMQon0CfD0xAbZPNDg/videos the caffeine concentration time course in You may be surprised to hear this, but caffeine is virtually never the cause of insomnia. the body) and the pharmacodynamics of The occasional difficulties falling asleep if you have more coffee at a later time than you caffeine (PD: the response of the body to normally would, absolutely. Caffeine could be the culprit. Constant or intermittent insomnia caffeine concentration in the blood). The for weeks or months, very unlikely. This is important to know because giving up coffee, effect and concentration of caffeine peaks or anything else you enjoy, increases the influence insomnia has over your life. And for no about 45 minutes after consumption and reason. decays exponentially with a half-life of 1.5 hours. Hence, four hours after caffeine Dr. Amy Bender, senior research scientist, Calgary Counselling Centre; sleep consumption, for example, the effect and performance expert concentration of caffeine are about 25% of Twitter: @sleep4sport their peak values. Caffeine causes more arousals, longer sleep latency and potentially an effect on slow Dr. Ian Dunican: wave activity, so not just the sleep parameters but more the brain wave activity. Per some research studies, if you are sleep restricted, caffeine can benefit you for a short period of I would like people to know that everybody time, but after the third day it seems to impair your performance. One of my quotes for is different. We are not all like machines. World Sleep Day was “Use caffeine strategically; not automatically.” I think if people are This is the problem. People kind of think addicted, that they have to have their coffee every morning, that can become problematic. like engineers, like inputs and outputs, but we are all different. I am sure we all What are your thoughts on “caffeine ” where a person know people who can drink coffee and drinks coffee prior to a short nap? Sometimes referred to as go to bed and be knocked out straight a “nappuccino.” Dr. Jacques Reifman: I understand that this “old” idea came back last year with Daniel Pinks’ publishing of “WHEN.” I have not seen studies that support this idea, which does not mean they do not The effect and exist. With that said, “sleep is sleep,” meaning the sleep community currently believes that sleep is always beneficial, even if it is a short nap. Separately, caffeine promotes alertness. concentration Hence the idea of short naps (20 minutes) seems to make sense, because it takes about 45 minutes for the full effect of caffeine to take place. of caffeine Dr. Ian Dunican: peaks about 45 I think it is good. What we have seen is it’s recommended a lot here in Australia where people have to drive long distances, and there are lots of problems with people experiencing micro-sleeps, or driving long distances such as 30 hours or more. This gets minutes after back to the pharmacokinetics where the caffeine kicks in after the nap of 20 to 30 minutes, and it will help to negate the sleep inertia. consumption.

Dr. Marta Maczaj: Caffeine naps can be very useful to get through the second half of your work day if you are away without a problem. For me, I’d be severely sleep deprived or jet lagged. Schedule a 20-minute nap around 2-3 p.m. and have bouncing around like a frog for two or a cup of coffee or tea/caffeine. When you are waking up after your nap, the caffeine is three hours after consuming caffeine kicking in and making it easier for you to awaken. at 7-8 p.m. at night. So, everybody is Dr. Amy Bender: different as to how they metabolize In general, I am not a fan of the caffeine nap because the caffeine can stay in your system caffeine, and people like Dr. Amy Bender at night, therefore impacting your nighttime sleep. So, if I take caffeine at 3 p.m., it’s going and Dr. Nanci Guest have done some to impact my nighttime sleep and, therefore, I think just having a nap — a short power work on this so they can offer more on nap — is more beneficial than the nap with caffeine. this than I can.

Quarter Three 2019 A2Zzz 22 Dr. Marta Maczaj: when I went off caffeine. I eliminated The half-life of coffee is around 4.5 hours. It usually takes three half-lives before caffeine coffee, but then I would replace it with is totally eliminated from your system, and this should be taken into consideration when black tea, and it took me two weeks to having your last cup of coffee. Some people metabolize caffeine more slowly (or more be to the point where I wasn’t tired and rapidly), and the caffeine can last a longer time in their system and can interfere with exhausted from not having that much nighttime sleep. Some individuals are very sensitive to caffeine, and the caffeine can also caffeine. I would be really tired in the cause a sense of nervousness, an increase in heart rate and also contribute to insomnia. morning and have a black tea. I may then be tired in the afternoon so I would have a Dr. Daniel Erichsen: green tea and then I just gradually started Having a cup of coffee can help you stave off the fatigue and inability to focus that often reducing that to only needing the green tea. comes with trouble sleeping. Use common sense. If you are sensitive to caffeine, then having a Red Bull in the evening is probably not a good idea. But, most importantly, know Can you give me an example that what is often considered part of the problem can become an important part of of how caffeine negatively the solution. impacted performance of one Dr. Amy Bender: of your patients or athletes? Everybody has a different metabolism for caffeine. The go-to study that I refer to a lot is from Dr. Nanci Guest (https://www.ncbi.nlm.nih.gov/pubmed/29509641). She found that Dr. Ian Dunican: in cyclists, when given caffeine, their performance was based on genotype, so those who The best example of this would be the caffeine usage in a paper we published about caffeine use in a super rugby team (https://www.ncbi.nlm.nih.gov/ Caffeine is a vasoconstrictor, and pubmed/29431593). Basically, all the guys had various levels of caffeine consumption removing caffeine causes vasodilation before the game and during the game. Afterward, the caffeine level was very high in some players. What was really and can lead to headaches due to interesting that didn’t make it into our paper was that some of those athletes the vasodilation. who had the highest amount of caffeine really had issues with performance during the last quarter of the game — the last 20 minutes. Going forward, for the following were slow metabolizers of caffeine actually performed worse than those who were fast season we advised the team dietitian/ metabolizers. And for the fast metabolizers, it was really beneficial for them. So, I think nutritionist to devise a caffeine strategy: you really have to be careful about making the assumption that caffeine is beneficial for the timing of caffeine, dosage of caffeine, everyone all the time. in relation to player body weight.

How does caffeine detox affect a person? Do you recommend Dr. Marta Maczaj: cold turkey or gradual withdrawal? One of my insomnia patients drank Red Dr. Ian Dunican: Bulls in the evening after dinner. His This would be a personal thing. All I ever do is drink caffeine. I don’t drink or smoke. So, insomnia improved after he stopped when I have been off caffeine, it’s been tough. So, I’m not sure on that one. It depends on drinking the Red Bulls! the person.

Dr. Marta Maczaj: BRENDAN Death before decaf! Just kidding! I would not recommend rapid detox. The individual DUFFY, RPSGT, will develop headaches. Caffeine is a vasoconstrictor, and removing caffeine causes RST, CCSH, is an vasodilation and can lead to headaches due to the vasodilation. The person can also AAST board feel much drowsier during the day and may have drowsy driving. I suggest a gradual member and a withdrawal. Consider half caffeine and half decaf for all your cups of coffee for a few days, then decrease to one-third caffeine and two-thirds decaf for a few days, then one-quarter certified sleep caffeine and three-quarters decaf for a few days, and then all decaf. educator. He is a former travel Dr. Amy Bender: baseball/hockey coach and has been I recommend gradual. I didn’t really drink caffeine until college and grad school — about employed in sleep medicine clinical settings two cups a day every single day for years. For me, the gradual method worked really well for over 20 years.

Quarter Three 2019 A2Zzz 23 The Pros and Cons of Group Setups By Sarah Brennecka

More and more labs are facing less reimbursement on studies. This forces the How to Perform an administration to look at how we can maximize our potential of studies while still giving excellent care. One of the ways might be looking at group setups, whether that is home Effective Group Setup sleep testing or PAP setups. 1. Organize prior to patient arrival. a. Use a setup folder that the patient PROS CONS will be able to take home with information in it. More minds equals more ideas. Not everyone can meet at b. Set the device for the patient prior to The more people you gather together, that allotted time. them arriving. the more ideas that will be generated. Allow time for other individual sessions c. Have information and instructions in Questions will often get asked that one also during the week. Setting a cut-off time the folder. wouldn’t think to ask if they were solo. the patient would be allowed to arrive until d. Get the sign-in sheet (HIPAA consent is necessary. Example: If the appointment form) ready. They are more time efficient. is at 7 p.m., then 7:15 p.m. is latest they Group setups should allow the lab to can arrive for their setup. It’s important to 2. Structure your room. maximize amount of studies per week. A stay on time for yourself and for the other a. Have a demo set up for the instructor. positive approach when scheduling these patients involved. b. Use name plates (it’s important to patients is very important. Some patients identify patient by name). may be hesitant. Managing up will be key, Not all patients will and it will start with the schedulers. qualify for a group setup. c. Have a clerk or administrative assistant help with the paperwork It’s important to research the patient, in It’s more cost effective. detail, prior to scheduling. Some patients so the clinician can focus solely on Reimbursement and in-lab approvals will need extra attention that will prolong a patient care. are becoming a challenge for labs. group setup. Those patients will need one- d. Use a flip chart to state your three Group setups will maximize the on-one appointments. objectives for the class. potential of getting more studies in e. Go over each piece of the equipment throughout the week. Not having adequate space. step by step. Allow space for family members to join in. f. Allow time for questions at the end. Often times the patient will be bringing a Refer back to the objectives flip chart family member along for comfort. to ensure all items were covered. If a patient still has a lot of questions, spend a couple extra minutes after class is over with them.

SARAH BRENNECKA, is the manager of sleep services and DME at Northwestern Medicine. She is also a member of the AAST Strategic Content Council.

Quarter Three 2019 A2Zzz 24 TRENDS

Today’s Trends in Sleep Technology: From ‘Trade’ to ‘Profession’

By Matthew Anastasi, BS, RST, RPSGT

Welcome to the second Trends article, a new A2Zzz department. In the previous Trends, we to evaluate for nocturnal seizures versus explored the shift to high-acuity patients in our centers, what is driving it and how best to parasomnias, and the most effective way respond. In this edition, we’ll give a perspective on why and how the field itself has evolved to accomplish this is to offer a diagnostic from a “trade” to a “profession” to meet the needs of the complex patient and numerous in-lab test that offers a full 10-20 hookup. other demands in our modern sleep centers. And as is par for the Trends format, we’ll Unless the technical staff has training provide recommendations on how you as a sleep professional can stay ahead of this in EEG montages and the additional change. procedures needed to safely manage patients with epilepsy — many labs will end “Everything we know, we learned from someone else.” —John Wooden a study and call a code for any convulsant “Did you go to school to learn this?” is a question we get a lot from patients. In sleep, seizure, whether localized or not — in particular, the answer varies depending on how you get into the field and is rarely a significant training in testing and workflow straightforward “Yes.” Think of your own entry into the field: Likely, it followed from an protocols will be needed to treat even one of interest in the subject for a personal reason, maybe a friend or family member who was these patients safely and effectively. diagnosed with sleep apnea, or out of curiosity. You may have applied related professional training or education to qualify for your first job in the field; you may have learned sleep Scenario B: Adjusting to a technology through OJT or “on-the-job training.” Patient Advocate Role The Elements of a Skilled Trade The complex patient increasingly needs support during the day to prepare for History tells us that most occupations start out as a trade. A tradesperson refers to a a safe and high-quality study at night. worker who learns the skills of their trade on the job, at times through an apprenticeship Arranging and performing testing role. This model is familiar to many of us in the field, and reflects how new a field sleep procedures like HSATs, PAP NAPs and technology really is. Think back to how you learned your first 10-20 setup, biocalibration, other versions of mask accommodation PAP titration, scoring, etc. It’s in the laboratory policy and procedure manual, but most of for PAP adherence, and advanced us learned by doing. treatments like ventilator transition and advanced titration require more daytime The Latent Demand for Competency staffing support than ever. Skills needed But back to our Trends. Sleep has matured to the point where we: to organize the insurance authorization are different than what is typically • Treat more acute patient populations (reviewed in the previous Trends article) in need of needed for the sleep technologist role. more regimented safety protocols. Communicating with durable medical • Experience additional regulatory oversight. equipment (DME) care providers to • Perform more comprehensive insurance pre-authorizations. facilitate treatment and ensure the • Provide a broader range of specialized and complex treatment options. pathway to treatment moves along smoothly requires a different level of oral In practice, these transformative changes are great for patient safety, treatment and written communication than has been effectiveness and cost control. And they reflect changes in healthcare in general. However, part of the scope of practice in the past. comparatively speaking, sleep has experienced growth and change in a shorter span than most medical fields, some of which have been around decades longer than sleep, and this naturally opens up gaps in care — “growing pains,” if you will. One of these gaps has been Scenario C: Safety the latent demand for staff at the competency level needed for today’s sleep center and Protocol and patients. There are limits to how effectively someone new to the field can be brought up Communication to the competency level needed in the modern sleep center when on-the-job training is the Acute patients require a higher level of only avenue. care to mitigate the risks they present to themselves, to staff and even to other Scenario A: The Seizure Montage patients. Newer skills needed to navigate For a real-world example, imagine your center, which is comprised of pulmonary physicians, in a sleep center include the use of more decides to bring on a neurologist to see sleep patients. From day one, there will be a need rigorous patient contact precautions

Quarter Three 2019 A2Zzz 25 and disinfection protocols; knowledge of medication effects on the performance of can position yourself in the right place for PSG and storage of patient meds; safe transfer of patients with limited mobility; safety the changing times. huddles and a need for a more fact-based “SBAR” (situation/background/assessment/ The sleep profession has been a full-time recommendation) structure to communication; and many more that impose a higher occupation for some time (and, for many demand for technologist education and communication than ever before. of us, more than full time), which meets the first pillar of a professional occupation. Trending Demands Before we review how the field has kept pace thus far, let us summarize the trending Education (Pillar #2) demands that have brought us to this place: Education, for the most part, makes for a • A need to broaden skill sets to include additional diagnostic (e.g., HSAT, capnography, well-rounded person. EEG montage) and treatment (e.g., neurostimulators, advanced titrations, PAP NAPs, In order to succeed in the medical field a ventilators) approaches. formal degree, which is built upon basic • The increasingly complex workflows that go along with these procedures to optimize courses like English, mathematics, rhetoric safety and quality. and writing, as well as sleep technology, • The learning and communication skills needed to adapt and work together effectively is important for communication and as a care team. interpersonal effectiveness in the Keep in mind that few of these skills were in widespread use in sleep centers just several workplace. It teaches how to organize years ago, especially in the adult population. thoughts, formulate action plans, solve problems — all skills needed in the The Pillars of a Professional Occupation complex workplace where a modern sleep professional is always learning In the transformation from trade to profession, a framework is typically followed: about emerging technologies, adapting to 1. An occupation becomes a full-time occupation. changing workflows, communicating with administrators and medical staff as well as 2. A training program or university curriculum is established. patients and co-workers, and staying up to 3. Local and national associations are developed to standardize practice and date on changes in the field and role. professional ethics. Though we are one of the few allied 4. Regulations and/or state licensing laws are established (Wikipedia, 2019). health fields that accepts supplementary A profession arises when any trade or occupation transforms itself through “the programs — most credentialing agencies development of formal qualifications based upon education, apprenticeship, and require a formal degree (e.g., medical examinations, the emergence of regulatory bodies with powers to admit and discipline assisting, surgical technologist, physical members ….” (Bullock & Trombley, 1999). therapy) — it can be demonstrated A profession is an occupation founded upon specialized education. Therefore, that formal education gives the sleep education is a key tenet of a modern sleep professional. With the typical professional a better foundation to profession framework understood, let’s take a look at how build upon. our field has developed and how you specifically Plus, any degree affords you the ability to continue your education in sleep or other sciences, and even unrelated fields. Education precipitates further education, 4 and once you have a formal education degree, it never expires. 3 With the advent of distance and online learning, it is easier than ever to attend a 2 polysomnography technology program. There are 42 nationwide post-secondary 1 certificate and associate degree programs in polysomnography accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). You can enroll either part time or full time in some of the programs. These programs specifically train sleep technologists in the tasks required for the job and the skills needed to acquire new information quickly and effectively. OCCUPATION EDUCATION ASSOCIATION LICENSING STATE

Quarter Three 2019 A2Zzz 26 With financial assistance, community colleges are more affordable than ever and are practices in research, clinical, and set up to allow for continuation to a higher degree (accepting most basic English, math, educational realms through regional communication, etc., credits toward a higher degree). conferences and networking opportunities. How can you not be for education? Credentials (Includes Association (Pillar #3) Ethics from Pillar #3) At the national level, the American Association of Sleep Technologists (AAST) has been Sleep technologists can earn a certified the driving force in coordinating the effort to transform our field from a trade orientation credential from the Board of Registered Polysomnographic Technologists (BRPT) to a full-fledged profession. With a board that sets a vision for the ongoing viability of and the National Board for Respiratory the field and committees that promote the highest standards in conferences, legislative Care (NBRC). The credential holder must action, CECs, competencies through standards and guidelines, education, strategy adhere to a code of professional ethics or and existing and emerging technology, AAST is a high point in our field’s standing as a forfeit that credential. For example, from profession. AAST prepares sleep professionals for a changing workplace through an array the BRPT: All RPSGT applicants/certificants of continuing education offers from national meetings and partnerships with regional shall abide by BRPT’s Standards, Rules meetings to online education with CECs and publications. and Procedures Regarding Ethical and At the local level, more than 40 states have sleep societies with a mission statement Professional Review and Complaints that aims to serve the interests, both professional and through public policy, of sleep (“Rules and Procedures”), and all other professionals by state or region. Most provide a robust forum for the sharing of best BRPT rules, policies and procedures. The BRPT may take review action against any individual who fails to meet these requirements. Such review action may include, but not be limited to, suspending or revoking a RPSGT applicant/certificant’s certification, or declaring a RPSGT applicant/certificant’s candidate ineligible for certification (BRPT, n.d.). State Licensing (Pillar #4) Many states require licensure with a certified credential like the RPSGT, while others practice under a respiratory care act and exempt sleep technologists. A few do not define sleep technologists in any licensure act (AAST, n.d.). The point is that there is tremendous variation from state to state. It is very important that you understand what is required in your state. What is sufficient to practice in one state may not be accepted via reciprocity in another state. What this means for you is that the more education and certified credentialing you have, the more likely you will be to meet your state’s minimum requirements. The particular licensure pathway chosen ensures that each sleep technologist is qualified based on education, training and

Quarter Three 2019 A2Zzz 27 experience, as well as a certified credential (e.g., typically a state license requires certification in RPSGT from the BRPT). Make certain what certified credentials are accepted in each state. As a sleep professional in your chosen field, you need to be personally involved in these basic questions. What Questions for education level is needed? What credential is needed? This impacts your status in your state Sleep Professionals and ability to be employed. Be aware of credentialing minimums in job postings. Minimum competencies are changing as employers see the vulnerability in not hiring staff that meet to Consider their payers’ and facility credentialing agency minimum staffing competency requirements. • As a potential applicant, do you Risk management, medical, administration and human resources departments are think your employer would prefer increasingly aware of the need for competent staff to work in an increasingly complex someone with formal education? environment, and this means that a sleep center or clinic that allowed OJT in the past now requires sleep credentialing at time of hire or within a defined time period after hire. • Would your education and credential be valuable at a sleep disorders Notwithstanding the employers’ attention to credentialing, some 40 states and counting center that handles acute patient have some type of regulation in place (which may include either a licensure pathway or populations and provides a wide exemption in their state legislatures). range of sleep services? • Would your education and credential Staying Ahead of the Curve: The Practical Pitch for Sleep be a predictor for success in one of Professionals the new sleep roles such as sleep Imagine this jarring real-world experience. You are sitting on a group workplace call when manager, clinical sleep educator or the director says those words that no one wants to hear: There will be staffing reductions. sleep navigator? Put yourself in the position of a decision maker. You can keep those with seniority, education or credentials. Which is the best way to separate the more competent from the less? Lessons learned from this type of scenario (without going through this experience) are to increase your competency level proactively and make yourself valuable at your 2. Bullock, A & Trombley, S. The New Fontana current job and marketable for the next. This means that as a bare minimum you should Dictionary of Modern Thought, London: Harper-Collins, 1999, p.689 3. BRPT. (n.d.). Retrieved June 29, 2019, from https://www.brpt.org/ethics/standards-of- With so many advances in clinical conduct/ 4. AAST. (n.d.). State Support Directory. practice, technology, industry, Retrieved June 23, 2019, from https://www. aastweb.org/state-support-directory research, insurance, regulatory ... there MATTHEW is always something new to explore. ANASTASI, BS, RPSGT, RST, is the CEO of Limina Sleep Consulting aim to: a) acquire at least one certified sleep credential; b) work toward an associate’s LLC. He has served degree in polysomnography or a bachelor’s degree; and c) join your national and local the field of sleep professional organizations. medicine as a manager, technologist, author, researcher, Conclusion conference organizer and volunteer for 20 In each issue, you can seek out this column for a snapshot of a leading-edge development years in a variety of clinical and research in the sleep field and some practical advice on how to adapt and implement an approach settings, including the University of back at your sleep center, practice or clinic. With so many advances in clinical practice, Pennsylvania, Main Line Health System and technology, industry, research, insurance, regulatory or something else, there is always the University of Pittsburgh Medical Center. something new to explore. Today is an exciting time to be a sleep professional. If you He is the past president of the Pennsylvania encounter a challenge that you need a solution to, please feel free to reach out to me Sleep Society, secretary/treasurer of directly for consideration for a future article. CAAHEP’s Committee on Accreditation for PSG Technologist Education (CoA PSG), and References chair of the AAST Standards and 1. Profession. (2019, June 19). Retrieved June 29, 2019, from https://en.wikipedia.org/wiki/ Guidelines Committee. He can be contacted Profession#cite_note-11 at [email protected].

Quarter Three 2019 A2Zzz 28 IN THE MOONLIGHT

With Kristina Weaver, RPSGT

KRISTINA Where was your first job in What do you like most about WEAVER, sleep technology? your profession? RPSGT, is the My first job was at Health First in Cape Making a difference with so many neurodiagnostic Canaveral, Florida, in 2005. I went patients and my staff. It’s awesome manager for from the ER to their sleep center. What Parrish when a patient calls you up and tells you a change! Healthcare’s they had the best night of sleep of their Sleep Disorders life. Or when we see a hospital patient Why did you become an Center. She has been involved in sleep stop getting readmitted once their AAST member? medicine for 13 years. Prior to that, she severe sleep apnea is treated. was a paramedic. Weaver is the You know the saying, “It takes a village”? coordinator of Brevard AWAKE. She also Well, the same goes for our sleep What do you do for fun on days off serves as the past president of the Florida community. We are at a vital time in from work? Association of Sleep Technologists and is our profession to prove we can make I love to jog and surf with my family. on the AAST Board of Directors. a difference. No longer is medicine a I have two young kids and an fee-for-service type practice. Sleep What did you want to be when you amazing husband. medicine falls in the prime state of the grew up? preventative healthcare sector. AAST is What is the biggest change you The only job I have ever had out of here for education and networking and the medical field was a life guard in have seen in the profession since high school! I have always wanted to to help us strategically thrive in this new you started? do something in the medical field. My way of the future of medicine. It’s so cool how much sleep awareness original goal was nursing. I’ve been in Who has had the greatest influence there is out there now. You see schools, the medical field since I was 17. on your career? trucking companies, sporting teams and Why did you decide to become a Jeremy Bradford, an old boss of mine. employer groups asking for sleep help. sleep technologist? Through his mentorship and motivating We never saw that years ago. We need I was a paramedic and so burnt out me, I was able to think creatively and to keep this momentum going. from the ER and the unknown of going start our sleep navigator services eight into patient’s homes. I actually just Any words of advice for people who years ago. This drastically changed my stumbled across the position and are new to the profession? career and has saved many lives. He is applied for it having no clue what a Always act like your loved one is the an amazing mentor who allowed me to “polysomnographic technologist” patient who you’re treating! You would was. I wanted something different create something so successful within want someone with passion and the while I finished school. What made our organization that it is now being me want to stay in the field of sleep done at many other organizations. I can knowledge to care for them. You be that medicine was, in the beginning of my never thank him enough for believing in person for all of your patients. And, of career, I did a sleep study on my dad. me and his trust. course, always think outside the box. He had severe sleep apnea and also had arrhythmias (one round of Vtach What is the most challenging part What are you professional goals in and a seven-second sinus pause). He of your profession? the next five years? refused treatment. A year later, he died When you hear someone say, “Oh, they I have a little over a year left to finish my of a heart attack in his sleep. That’s just died in their sleep,” that’s it. Or you master’s in healthcare administration. I when I knew that as a sleep tech I hear a hospital code at 3 a.m. and hear am looking forward to moving onto my could make more of a difference in doctorate eventually. My goal for the the sleep center than in the ER or on the patient had a heart attack and died. a nursing floor. Heart attacks are a We need to help our community connect next five years is to be able to contribute leading cause of death in the United the dots. I could say also insurance to more research in sleep medicine and States. We can truly help! companies — they can be challenging. chronic care management.

Quarter Three 2019 A2Zzz 29 Compliance Corner

With Laura Linley CRT, RPSGT, FAAST, and Jayme R. Matchinski, Greensfelder, Hemker & Gale, P.C.

OIG Releases Report on Medicare patterns of questionable billing. Thirty-five percent of providers with paid claims submitted at least one claim that did not meet Payments to Providers for either the proper diagnosis code (not supporting medical necessity Polysomnography Services for testing), same day duplicate claim (unbundling a split night In June 2019, the U.S. Department of Health and Human Service study or double billing for the professional component) or had an Office of Inspector General (OIG) released a report titled Medicare invalid National Provider Identifier (NPI). This finding was viewed Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements, A-04-17-07069. Background The mission of the OIG is to protect the integrity of the Department These audits and of Health and Human Services (HHS) programs as well as to the beneficiaries receiving services for these programs. The OIG’s assessments help mission is carried out through a network of audits managed by the Office of Audit Services (OAS). These audits and assessments help reduce waste, abuse reduce waste, abuse and mismanagement of HHS services. Other programs that support the governance of HHS are: and mismanagement of • The Office of Evaluation and Inspections (OEI), which evaluates and reports on practical recommendations for HHS services. improving program operations. • The Office of Investigations (OI), which conducts criminal, civil and administrative investigations of fraud and misconducted related to HHS programs, operation and beneficiaries. as necessitating further and future scrutiny of sleep study service • The Office of Counsel to the Inspector General (OCIG), which providers to prevent inappropriate payment for polysomnography is the legal arm supporting the OIG. The OCIG renders advisory services as well as to take appropriate action regarding opinions, issues compliance program guidance, publishes fraud inappropriate payments and providers that exhibited patterns of alerts, and provides guidance regarding healthcare industry questionable billing. concerns such as the Anti-Kickback Statute and other OIG enforcement authorities. Current Report The OIG has reviewed polysomnography services and released The 2019 report on Polysomnography Services is based on a a previous report on Questionable Billing for review from Jan. 1, 2014, through Dec. 31, 2015. It was determined Polysomnography Services in that Medicare (MCR) paid $755 million for polysomnography 2013, and the OIG found that services, specifically procedure codes 95810 and 95811. The OIG Medicare paid for service then reviewed a stratified random sample of 200 beneficiaries that did not meet Medicare with 426 corresponding lines of service equaling a payment of requirements. This 2013 $148,198. Of the 200 selected, 117 did not meet MCR billing nationwide study reviewed requirements, resulting in a net overpayment of $56,668. The OIG over 626,000 claims for 2011 stated that based on the sample results, the OIG estimated that totaling $470 million from 7,232 MCR made overpayments of $269 million for polysomnography providers for 461,363 individual services during the audit period. The conclusion was that the beneficiaries. The OIG review Center for Medicare & Medicaid Services’ (CMS) oversight of identified nearly $17 million sleep services was insufficient to ensure that providers complied in payments for services with MCR requirements or to prevent payment of claims that did with inappropriate diagnosis not meet those requirements. Without periodic review of claims, codes, missing required MACs were unable to determine whether providers had received supporting documentation, payment for claims that did not meet MCR requirements or to take and providers that exhibited remedial action.

Quarter Three 2019 A2Zzz 30 Compliance Corner continued

With Laura Linley CRT, RPSGT, FAAST, and Jayme R. Matchinski, Greensfelder, Hemker & Gale, P.C.

What OIG Recommends necessity of testing, and documentation that the diagnostic testing is not duplicative of previously completed testing. The OIG recommends that CMS instruct the MACs to recover the portion of the $56,668 it identified as the net overpayments, and AAST has created an interactive state map that compiles legal that CMS work with the MACs to conduct data analysis allowing and licensure information, CMS requirements and sleep society for targeted reviews of claims for polysomnography services while information specific to each state. Members can review the educating providers on properly billing for polysomnography services. statutory language for sleep technologists, coverage policies for continuous positive airway pressure therapy for obstructive sleep Provider Compliance apnea, and find information about state sleep societies to review their issues and updates. The interactive state map is available to It is critical that providers understand the requirements for billing AAST members only here: State Sleep Resource Map. sleep services to MCR. The majority of overpayments are due to inappropriate diagnosis codes and related documentation. Coverage The December 2017 A2Zzz Compliance Corner reviewed the LCD of polysomnography is limited to diagnoses of narcolepsy, sleep regulatory standards for Polysomnography. apnea, impotence and , which must be documented in The Medicare Benefit Policy, Chapter 15, Section 70, is another the medical record. Each MAC assigned to process claims includes resource available for service providers. CMS does offer articles a comprehensive list in its Local Coverage Determination (LCD). and education with their Medicare Learning Network (MLN) To prevent denials, make sure you maintain a record of the platform. You can sign up to connect to new offerings through attending physician’s orders, office visit notes that support CMS’ listserv.

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Quarter Three 2019 A2Zzz 31